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In 1996, the incidence of amputations most commonly occurred because of vascular conditions and trauma.
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Dysvascular amputation rates were 8 times greater than trauma-related amputation rates in 1996.
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The number of amputations among patients with diabetes is declining, but the number of patients with diabetes is increasing because of early diagnosis.
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The number of amputations among elderly patients with peripheral arterial disease is declining.
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The combined illness burden of multiple comorbidities
Physical Medicine and Rehabilitation Clinics of North America
Epidemiology of Limb Loss
Section snippets
Key points
Dysvascular
Nationally representative hospital discharge data from 1988 to 1996 from the Healthcare Cost and Utilization Project (HCUP) showed that overall, dysvascular-related amputations were increasing as reported by Dillingham, Pezzin, and MacKenzie3 in 2002. Increased rates were evident in levels associated with considerable functional impairments, such as the foot, transtibial, and transfemoral levels. Incidence rates of dysvascular amputations increased with age in both sexes and racial groups when
Diabetes
Diabetes, a common comorbidity associated with dysvascular disease, affects 25.8 million people.4 Those patients with diabetes mellitus have an approximately 10-times higher risk of amputation compared with individuals without diabetes.5 Racial disparities continue to play a role in the course of diabetes. In general, the risk of diagnosed diabetes was 18% higher among Asian Americans, 66% higher among Hispanics, and 77% higher among non-Hispanic blacks compared with non-Hispanic whites.4 A
PAD
When in its end stage, PAD can lead to lower-extremity amputations.13 PAD and lower-extremity amputation rates were evaluated among elderly patients using Medicare part A beneficiary data from 2000 to 2008 by Jones and colleagues14 (2012). They found a decline in the overall annual rate of amputations in patients with PAD from 7258 per 100,000 to 5790 per 100,000 among patients with PAD over that 8-year period. Male sex, black race, diabetes mellitus, and renal disease were all independent
Reamputation rates
Reamputation and mortality rates are important to evaluate when considering rates of amputations. In 1980, Ebskov and Josephsen17 reported from the 1972 Danish Amputation Register that the incidence of ipsilateral reamputation is high in the immediate postoperative period, with 10.4% after 1 month, 16.5% after 3 months, and 18.8% after 6 months. After 4 years, the incidence was 23.1%. However, the contralateral limb's risk of amputation is constantly present, with an incidence of 11.9% within
Trauma
Trauma is the second most common cause of amputations, yet occurs at about one-eighth of the frequency as dysvascular amputations overall. Dillingham, Pezzin, and MacKenzie19 examined population-based hospital discharge data for Maryland from 1979 through 1993. The incidence of major amputations declined 3.4% annually and 4.8% annually for minor amputations (Table 2).19 Although PAD and diabetes were most commonly associated with lower-limb amputations, upper-limb amputations accounted for the
Cancer
Limb loss caused by cancer in the United States is rare compared with dysvascular causes, occurring at less than one-one hundredth the rate of dysvascular amputations. In the United States, primary malignant bone tumors are 6% of all cancers in children younger than 20 years.26 Osteosarcoma and Ewing sarcoma are the 2 predominant bone malignancies that affect the long bones and central axis.26 Dillingham, Pezzin, and MacKenzie3 found that most cancer-related amputations were in the lower
Congenital deficiency
Congenital limb deficiency may be caused by genetic variation, exposure to an environmental teratogen, or gene-environment interactions.15, 16 Birth prevalence rates ranged from 3.5 per 10,000 births (including pregnancy terminations) to 7.1 per 10,000 births.15, 16 The birth prevalence of limb deficiency in children with major congenital anomalies was 12.9 per 10,000 births.27 Analysis of the HCUP data by Dillingham, Pezzin, and MacKenzie3 revealed that the incidence of congenital deficiencies
Summary
Literature from the last 2 decades demonstrates that the rate of amputations among dysvascular patients was 8 times greater than those with trauma-related amputations. However, recent studies have shown a reduction of the rates in subsets of those with diabetes and PAD, which may be attributed to the early detection of conditions and preventive programs. Additionally, the role of a combined illness burden may have a stronger impact on the risk of amputation compared with single disease
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Partially supported by grants 2R42HD069067-02 (TRD) and HD042588R01 (MGS).